Cardiac Sleep Review (CSR) talks with Daniel Bensimhon, MD, Medical Director of The Advanced Heart and Mechanical Circulatory Support Program at Moses Cone Memorial Hospital in Greensboro, NC. Dr. Bensimhon is an Advanced Heart Failure cardiologist who treats patients with all levels of heart failure—from very mild (Class II) to patients who need full mechanical support and referral for cardiac transplantation (Class IV).
CSR: There are interventional cardiologists, electrophysiologists, imaging specialists, among other specialties in a cardiology department. Why the need for a heart failure specialist?
Dr. Bensimhon: Cardiology is becoming more and more subspecialized. We’re seeing more technologies and new devices in all fields of cardiology, especially in electrophysiology and interventional cardiology to help support people in cardiac distress. We’re finding that as people are living longer, surviving their heart attacks and living with heart failure, we need more and more treatment options in heart failure as well. The care of these patients is becoming more sophisticated and more complicated. There are new pharmaceutical agents and new devices coming to the market. So, providing care for this potentially very sick patient population has warranted its own subspecialty of clinicians trained to care for patients with advanced heart failure and the issues that go along with it.
CSR: How do you collaborate and work with the other specialists within cardiology?
Dr. Bensimhon: There are still many smaller practices in the country where they don’t have the ability to have multiple specialists. We have over 40 cardiologists in our group who all work well together. Although we are in a large community center, we function much like an academic program. Many of the complicated patients require services from general cardiology, but we still need imaging, interventional and electrophysiology support as well. We work hand-in-hand. They rely on us to take care of the sickest heart failure and shock patients and we rely on them for interventional procedures and devices and to refer their appropriate patients to us in a timely fashion, so that we can offer therapies before it’s too late.
CSR: Could you describe the patient population that you treat in the clinic?
Dr. Bensimhon: We have about 3000 patients in our outpatient Heart Failure clinic. About two-thirds of them have systolic heart failure or HFrEF where their heart muscle is actually weak, and the other third have diastolic heart failure or HFpEF where their heart function is actually preserved, but they have a stiff heart. Many of these patients are very limited. They have symptoms with minimal activity. They struggle with additional fluid overload and it’s quite intense to manage not only their volume status but to make sure that we’re treating their comorbidities. We want to make sure we are addressing everything that we feel affects their heart failure and functional capacity. We’re getting them on guideline-directed medical therapy, having devices implanted, referring for rehab, placing heart monitors, and ordering sleep studies.
If those strategies aren’t enough to optimize a patient, we then consider our advanced therapy options. There’s a lot of data now that says these patients are difficult to treat, that the majority of these patients aren’t on the guideline-directed medical therapies, and that they are under-treated. Our focus is to be very aggressive and make sure these patients are treated as aggressively as possible before we turn to an LVAD or transplant.
CSR: From your perspective, what’s the connection between sleep apnea and heart failure?
Dr. Bensimhon: I think we’ve realized for a long time that there is a link between sleep apnea and worse cardiovascular outcomes in our patients. That said, not all the data has been consistent. There’s been a direct link between untreated sleep apnea and atrial fibrillation and hypertension —both of which are huge risk factors for congestive heart failure. Unless you get their sleep apnea under control, you are not going to get those risk factors under control. Whether or not there is a direct link between sleep apnea and worsening heart failure outcomes or it is mediated by these risk factors remains unclear. In our clinical experience, certainly, it seems that heart failure patients with the worst sleep apnea are more symptomatic and have been more difficult to manage.
More recently, I think people are realizing that many of the abnormalities in ventilation that we see in sleep apnea, also occur in heart failure – and we see this frequently in our cardiometabolic exercise lab. Heart failure patients have a much higher incidence of central sleep apnea where the ventilation processes in the brain don’t work as well as they should and they can have very abnormal ventilatory patterns both during sleep and during activity.
There is a tighter and tighter link between undetected or uncontrolled sleep apnea and heart failure. One line that we’re still trying to connect is, is there a direct connection between the treatment of sleep apnea and improved heart failure outcomes. There has been some data on both sides of the fence saying that yes there’s a huge benefit and on the other side, maybe not. Maybe there could even be harm. We need more studies, more data to confirm what instinctively we know.
As I mentioned above, in our clinic, we see that with our patients who have sleep apnea and are under-treated or not treated, we have a much harder time controlling their risk factors. We have a much harder time controlling their hypertension, a much harder time controlling their atrial fibrillation; and most importantly, we have a really hard time controlling their symptoms. They come in and say that they’re fatigued, and we can’t tell if its heart failure or sleep apnea. What is it? Why are they so fatigued and why are they so limited? So, our goal is to address all their risk factors and to improve their sleep apnea symptoms to really try and get at what effect is it having on their heart failure. Personally, I think that there’s a very strong link between the treatment of sleep apnea and improvement in heart failure symptoms and potential outcomes. But the data we have so far has been limited and doesn’t completely support these observations. I don’t think we know the whole story yet. We still need more studies, more data.
CSR: What would be the best scenario for how you would describe sleep apnea management in the clinic?
Dr. Bensimhon: It’s different in every situation. Cardiology clinics come in many different forms. For us, in our Heart Failure clinic, it’s important for us to own the process. Given what’s on the line for these patients with advanced symptoms, we want to own the patient. If we think there’s something important that’s going to improve their heart failure, whether it be managing their fluid status or getting them an ICD, we’re going to manage that process. We’re going to start the therapy. We’re going to prescribe and implement that therapy. We’re going to follow up with them. With sleep apnea, we really haven’t had the ability to do that. What typically happens is that we say, “you need a sleep study.” We write the order and then we trust that the process works.
We need to own that process. We need to be able to get the patients to comply with testing and get them tested quickly. We need to see the results and know how bad the problem is. We then need to decide how hard we’re going to push to get our patients on therapy quickly. Finally, as with any therapy we prescribe, we want to be able to track compliance and outcomes. Are they using their CPAP? How often? How long? Is their AHI improving?
In our clinic, we are fortunate to have two cardiologists who are also well-trained sleep doctors. Nevertheless, as these are our patients, we want to own the process in conjunction with our sleep doctors, and work collaboratively with them to make sure patients are getting treated aggressively in a timely fashion. If our patients aren’t following up with their sleep doctor, we want to know about it so we can get them back to their sleep doctor and work on this. Our philosophy can be summed up by one word—ownership. Ownership of our patients and their outcomes every step of the way.
CSR: Prior to using the WatchPAT® TurnKey program, how were you diagnosing, managing, and treating cardiac patients with sleep apnea?
Dr. Bensimhon: As I said above, we’re fortunate enough in our practice to have two cardiologists who are also trained in sleep medicine. In the past, we would typically refer our patients with suspect sleep apnea to them for a sleep evaluation and potential sleep study. Many smaller cardiology practices are still referring patients to neurology or pulmonology or to internal medicine doctors who are also trained in sleep apnea.
The reason we started looking at the WatchPAT® device is that prior to using it there were many opportunities for a breakdown. We would see a patient in the clinic, and say “Hmmm, I think he or she may have sleep apnea” and then there’s a process that has to happen between the time of your suspicion and the time of effective therapy. There are several steps in that process.
- The first step is to get the patient to the sleep doctor to see if they agree with the need for a sleep study or not. This involved scheduling the patient for an appointment at another office and hoping they would keep their appointment.
- Step two. Once they were seen by our sleep doctor, the next step was getting them to agree to go to the sleep lab for a sleep study. Telling a patient who is relatively non-compliant and who might not get the link between sleep and heart failure isn’t often an easy sell. Basically, you’re saying, “You have to go to the hospital or somewhere and sleep in a strange bed for a night or two, and they’re going to put this mask on you…it didn’t always go over well.”
- Step three. Once you finally get them to agree to a sleep study, there’s typically a two or three-week waiting period before they get an appointment in the sleep lab–which they may or may not show up for — and then you have to wait for the results to be analyzed and get a report back; which can also take a few days.
- Step four. The patient had to follow-up with the sleep physician to determine the best treatment and implement therapy. If they’re diagnosed with sleep apnea, they’ll probably be prescribed a C-PAP mask. Finding the right mask and fit can be problematic. The patient may not like the first mask and just give up without ever working through the options. They drop out of sight and you have no idea what happened. Then they show up in the heart failure clinic in 4 months and you ask them how their sleep study went and over half the time they either never had their sleep study or they had it and didn’t get the results or couldn’t tolerate the mask and we never knew anything about it.
To be more successful in getting patients on therapy, we set out to own the process and break down the barriers at each step along the way. Things like,
“How can we make sure that the patient agrees to and gets scheduled for a sleep study before they leave our clinic? Can we send a device to their home and make the test simpler for them? How can we make sure that we get the results quickly and follow up on those results quickly? How do we connect the loop with the DME and make sure that once the study is positive, we have a DME that’s engaged and willing to follow them? And then once therapy is prescribed, how do we make sure they’re complying with their therapy and how do we monitor that? And most importantly, how do we get kept in the loop along the way?”
Those are the reasons for us using the WatchPAT® Turnkey. The desire to simplify the process and own the process– so it’s not able to break down at so many different touch points.
CSR: How has using WatchPAT® affected your practice and patient outcomes?
Dr. Bensimhon: We’re early on into the process—probably about 40 studies in. We operate in a larger practice and we want to have buy-in with our sleep doctors. We want to make sure that what we’re doing is not only good for our patients, but also works for our practice flow.
Currently, we see the patient in the clinic, and we order the device right then and there. The order goes out, and in a day or two, the device shows up at the patient’s house. The patient’s able to do their sleep study and we’re seeing the results very quickly. In fact, our pull-through rate has probably gone from 50 to 90 percent for prescribing and compliant use of the at-home sleep apnea test. Now we are focusing on working through the DME process to make sure that more patients are getting the therapy that works for them and setting up the WatchPAT® Cloud system so we can follow their progress in real-time.
CSR: Were you able to use the WatchPAT® system during Covid-19 for any of your patients?
Dr. Bensimhon: That was a major impetus. Typical sleep studies are an aerosolized procedure much like PFTs and exercise stress tests. So these were all completely canceled at our center for several months due to the high-risk of viral transmission and are still only done only on a limited basis.
The WatchPAT® offers us a way to not only continue testing but to do so in a much lower risk setting. The WatchPAT® can be done at home, is completely disposable, and does not utilize an airway component. Thus, we can reassure patients that not only are they getting the test they need but we are doing it in the safest way possible. At our hospital, we call this iCARE values and it means putting the patient first and saying, “We’re concerned about you.” So now we cannot only offer our patients easy access to testing, but we can offer testing in the convenience and safety of their own homes. Patients have responded dramatically well to this approach and we are actually doing more testing in our clinic now then we were doing before the COVID pandemic hit. It has been a true win-win so far.
Itamar WatchPAT® TurnKey Program